Health Care and Climate Change: Challenges and Pathways to Sustainable Health Care
Authors: Sarju Ganatra, Sourbha S. Dani, Sadeer G. Al-Kindi, Sanjay Rajagopalan
Journal: Annals of Internal Medicine (2022)

Ideas and Opinions25 October 2022Health Care and Climate Change: Challenges and Pathways to Sustainable Health CareSarju Ganatra, MD, Sourbha S. Dani, MD, MSc, Sadeer G. Al-Kindi, MD, and Sanjay Rajagopalan, MDSarju Ganatra, MDDivision of Cardiovascular Medicine, Lahey Hospital & Medical Center, Tufts University School of Medicine, Burlington, Massachusetts (S.G., S.S.D.), Sourbha S. Dani, MD, MScDivision of Cardiovascular Medicine, Lahey Hospital & Medical Center, Tufts University School of Medicine, Burlington, Massachusetts (S.G., S.S.D.), Sadeer G. Al-Kindi, MDDivision of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, and University Hospitals, Cleveland, Ohio (S.G.A., S.R.)., and Sanjay Rajagopalan, MDDivision of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, and University Hospitals, Cleveland, Ohio (S.G.A., S.R.).Author, Article, and Disclosure Informationhttps://doi.org/10.7326/M22-1241 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail Climate change strikes at the very core of health care's mission to keep people healthy. The health effect of extreme temperatures, forest fires, and natural calamities, and the expansion of the range of infectious diseases, are undeniably apparent (1). Health care delivery leaves an environmental footprint from the use of large quantities of natural resources to the generation of air pollution, vast amounts of waste, and substantial greenhouse gas (GHG) emission. Health care accounts for 8.5% of U.S. GHG emissions (2.5 billion tons per year) and 5% globally; similar fractions of toxic air emissions make it the fifth-largest source of GHG worldwide (2, 3).Twenty percent of the U.S. gross domestic product and 10% of the global economy are attributable to health care (4). Health care organizations (HCOs) are strategically positioned to help transform communities and markets in the new green economy by bringing sustainability principles to every aspect of health care, as recognized during the 26th Conference of the Parties (COP-26) in 2021 (5) and recently endorsed by the Department of Health and Human Services and the White House (6). However, there is a chasm between aspirations and policies: the real work of health care decarbonization still looms large. Most global and U.S. HCOs do not have sustainability principles in their mission statements. The reporting of GHG emissions and sustainability is neither mandated nor mainstream; other than a moral imperative, no levers exist to force HCOs to reduce GHG emissions.Getting to Net-Zero Health CareAn important first step is understanding the sources and magnitude of GHG emission, as classified by the 3 broad scopes outlined herein. Tackling GHG emissions and getting to net zero are mammoth tasks; HCOs can start by appointing an environmental sustainability and governance officer to facilitate carbon footprint measurement and oversee implementation of environmentally friendly measures.Scope 1. Direct Emissions From the HCOReducing the carbon footprint of HCO buildings is an opportunity to embed sustainability efforts that can achieve "early wins" because direct emissions from HCOs represent 7% of total GHG emissions (2). Large hospitals account for fewer than 1% of all commercial buildings but consume 5.5% of total delivered energy in the commercial sector (7). Simple measures—such as replacing conventional lights with light-emitting diodes (LEDs); electrifying heating, ventilation, and air conditioning; using energy-efficient equipment; minimizing power consumption by computers and laboratory instruments in idle time; and keeping air circulation in operating rooms to a minimum—can reduce costs and emissions (8). Avoiding chlorofluorocarbons by switching to natural refrigerants and limiting the use of volatile halogenated chlorofluorocarbon anesthetics (halothane, enflurane, isoflurane) or fluorinated hydrocarbons (sevoflurane and desflurane)—which have a magnified effect on global warming (>2000 times than CO2, >200 times than methane)—could reduce the GHG footprint (3). To collect unused anesthetics, HCOs may need to develop and use gas-capturing technology.Scope 2. Indirect Emissions by Energy and Utility SuppliersTransitions to clean energy sources and suppliers may help indirect reductions in emission intensity and facilitate adaptation of newer climate-friendly technologies (electric automobile fleets). To decarbonize their electric grid, HCOs could consider creating on-site sources of clean power generation and storage, and purchase energy generated from renewable sources. Although scope 2 GHG emissions are estimated to account for 11% of total GHG emissions (2), decarbonizing the energy grid could result in more reduction due to network effects.Scope 3. Supply Chain and Other EmissionsThis third scope, which accounts for as much as 82% of total GHG emissions (2), includes all other indirect emissions and represents the largest contributor to an HCO's carbon footprint: consumables used in health care, purchased goods and services, pharmaceuticals, transportation, emissions from a product or service provided, employee commuting, and waste generated from operations and its disposal. Given the complexities, scope 3 emissions remain extremely difficult to estimate. Both energy and emissions dense, single-use plastics make up at least 20% of medical waste generated in U.S. hospitals (8) and could be replaced by reusable equipment with appropriate sterilization and attendant savings in dollars and CO2 along the supply chain (9). Innovations in medical recycling systems may help tackle widespread waste. Procuring supplies from manufacturers transparent in their GHG emission reduction would be necessary. Finally, food transformation, comprising local food procurement, waste reduction and appropriate disposal, and promotion of healthy plant-based options, can also help HCOs alleviate their carbon footprint.Financial Tradeoffs of Net-Zero StrategiesBecause HCOs may not perceive that they are immediately and directly impacted by climate change, they may find it challenging to make the substantial upfront financial investments required to avert a distant existential threat that may not impact their financial statements. Although many climate-friendly options seem more expensive in the short term ("green premium"), some are reasonably affordable and even profitable in the long term. For example, Cleveland Clinic's investment in energy-efficient buildings appreciated 20% reduction in its energy consumption, leading to $50 million dollars in savings, by installing on-campus solar panels and more than 500 000 LED lights, expanding building automation controls to minimize idle-time energy use, reducing hourly air changes in unoccupied operating rooms, adjusting the discharge air temperature of noncritical units to reduce cooling and reheat loads, and retro-commissioning air handling units and calibrating and replacing the sensors that control them (10). Governmental subsidies and carbon credits may help with cost mitigation. Once the costs to communities impacted by health care pollution (including expenses related to health services, relief, and recovery from climate disasters) are accounted for, energy efficiency projects have repeatedly been shown to have a positive return on investment (10).Re-envisioning financing systems may be required to develop climate-friendly strategies in health care, without a substantial cost burden being passed on to our patients and society. Insurers can set reimbursement policies to favor low-emissions strategies over more carbon-intensive actions. Health care financing agencies could set "green" criteria for health care infrastructure and purchases. However, these changes could disrupt current reimbursement models and threaten the financial stability of HCOs. Governmental action may be needed to align reimbursement models to help accelerate HCO transformation toward net zero.Call to ActionGovernments and international organizations may implement broader strategies and policies to deal with climate change, but health care systems are on the frontlines of its adverse effects: we in health care cannot afford to sit idle. The Table describes many high-level changes health care stakeholders, policymakers, and clinicians can make to help reduce GHG emissions. Providing health care for all will not succeed without addressing the twin risk for environmental pollution and ecological catastrophes secondary to climate change. Health care has a moral imperative to reduce its emissions and environmental footprint and force transformation across all other sectors it touches. It is high time that the health care community acts.Table. High-Level Changes Clinicians and Health Care Stakeholders Can Make to Attain Sustainable Health CareReferences1. Rajagopalan S, Landrigan PJ. Pollution and the heart. N Engl J Med. 2021;385:1881-92. [PMID: 34758254] doi:10.1056/NEJMra2030281 CrossrefMedlineGoogle Scholar2. Eckelman MJ, Huang K, Lagasse R, et al. Health care pollution and public health damage in the United States: an update. Health Aff (Millwood). 2020;39:2071-9. [PMID: 33284703] CrossrefMedlineGoogle Scholar3. Health Care Without Harm. Health Care's Climate Footprint. Climate-Smart Health Care Series. Green Paper Number One. Accessed at https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf on 22 August 2022. Google Scholar4. World Health Organization. The Global Health Observatory. Accessed at www.who.int/data/gho on 22 August 2022. Google Scholar5. UN Climate Change Conference UK 2021. Delivering the Glasgow Climate Pact. The 26th UN Climate Change Conference of the Parties (COP26), Glasgow, United Kingdom, 31 October–13 November 2021. Accessed at https://ukcop26.org on 22 February 2022. Google Scholar6. U.S. Department of Health & Human Services. HHS Launches Pledge Initiative to Mobilize Health Care Sector to Reduce Emissions. Accessed at www.hhs.gov/about/news/2022/04/22/hhs-launches-pledge-initiative-mobilize-health-care-sector-reduce-emissions.html on 6 July 2022. Google Scholar7. U.S. Energy Information Administration. Energy Characteristics and Energy Consumed in Large Hospital Buildings in the United States in 2007. Commercial Buildings Energy Consumption Survey (CBECS). 17 August 2012. Accessed at www.eia.gov/consumption/commercial/reports/2007/large-hospital.php on 6 August 2022. Google Scholar8. Azouz S, Boyll P, Swanson M, et al. Managing barriers to recycling in the operating room. Am J Surg. 2019;217:634-8. [PMID: 29958657] doi:10.1016/j.amjsurg.2018.06.020 CrossrefMedlineGoogle Scholar9. Donahue LM, Hilton S, Bell SG, et al. A comparative carbon footprint analysis of disposable and reusable vaginal specula. Am J Obstet Gynecol. 2020;223:225.e1-e7. [PMID: 32067971] doi:10.1016/j.ajog.2020.02.007 CrossrefMedlineGoogle Scholar10. Chen A, Murthy V. How health systems are meeting the challenge of climate change. Harvard Business Review. 18 September 2019. Accessed at https://hbr.org/2019/09/how-health-systems-are-meeting-the-challenge-of-climate-change%20target= on 22 February 2022. Google Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAffiliations: Division of Cardiovascular Medicine, Lahey Hospital & Medical Center, Tufts University School of Medicine, Burlington, Massachusetts (S.G., S.S.D.)Division of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University, and University Hospitals, Cleveland, Ohio (S.G.A., S.R.).Grant Support: Dr. Rajagopalan was supported by National Institutes of Health grants 1R35ES031702, R01ES019616, and R01ES017290.Disclosures: Disclosures can be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M22-1241.Corresponding Author: Sarju Ganatra, MD, Lahey Hospital & Medical Center 41 Mall Road, Burlington, MA 01805; e-mail, sarju.[email protected]org.Author Contributions: Conception and design: S. Ganatra, S.S. Dani, S.G. Al-Kindi, S. Rajagopalan.Analysis and interpretation of the data: S. Ganatra, S.G. Al-Kindi, S. Rajagopalan.Drafting of the article: S. Ganatra, S.S. Dani, S. Rajagopalan.Critical revision of the article for important intellectual content: S. Ganatra, S.G. Al-Kindi, S. Rajagopalan.Final approval of the article: S. Ganatra, S.S. Dani, S.G. Al-Kindi, S. Rajagopalan.Provision of study materials or patients: S. Rajagopalan.Statistical expertise: S. Rajagopalan.Obtaining of funding: S. Rajagopalan.Administrative, technical, or logistic support: S. Rajagopalan.Collection and assembly of data: S. Ganatra, S. Rajagopalan.This article was published at Annals.org on 25 October 2022. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoEnvironmental Health: A Position Paper From the American College of Physicians Ryan Crowley , Suja Mathew , David Hilden , and Metrics LatestKeywordsCardiology and cardiovascular diseasesClimate changeEnvironmental healthHealth careHealth care qualityHealth care sectorHigh value careHospital medicinePollutionPrevention, policy, and public health ePublished: 25 October 2022 CopyrightCopyright © 2022 by American College of Physicians. All Rights Reserved.PDF DownloadLoading ...